Methotrexate - Easy to Use, Easy to Abuse
Saturday, July 11, 2009
Kenneth F. Trofatter, Jr., MD, PhD
Melissa O. said...
I was told I had an ectopic pregnancy and was advised I was in need of a Methotrexate shot. I got it. One week later my hormone level was continuing to rise. Low and behold 4 days later my ultrasound showed I was carrying twins. The Dr.'s had presumed ectopic too early. Getting the shot caused me to loose Twin A and to give birth to a very much underweight 28 weeker. This experience has changed my life forever. My son fought to survive...he continues to today now 13 months old. I would hope anyone who is told they have an ectopic pregnancy would be cautious when it comes to this shot. Yes I agree it helps if your life is in danger due to an ectopic pregnancy. Just take time to ensure there is no doubt that's what it is. My Dr couldn't see the baby so assumed ectopic, however carrying twins like I was you’re not able to see as early as a single pregnancy. My son is paying everyday because of my mistake and doing as one Dr. said make sure you have more than one confirmation, it could cost you a perfectly healthy baby in the end.
Fri Jun 19, 05:45:00 PM 2009
Anonymous said...
Hi can someone help me? My husband and I were trying for a baby and I fell pregnant (good news). I started having a few brown spotting and slight cramping which I was advised by my GP to go to the hospital for a scan. Whilst there I had many tests and the doctors thought it might be ectopic and said he was going to keep me in for a few days to monitor my blood levels. I had a scan but being only five weeks it was hard to say. I was referred to another doctor on the ward and he told me it was ectopic. I trusted his knowledge and he said he needed to give me methotrexate now as it was Friday so the pharmacy would be shut. I was shocked but agreed of course. 3 days later I was told the baby is still alive and is in my womb. My blood levels increased after 3 days and then decreased from 7000 to 6000 on the 7 days. How long will it take to lose my baby as it’s hard to know its alive?
Fri Jul 03, 11:15:00 AM 2009
Ever since methotrexate became popular for treating ectopic pregnancies, I have seen the unfortunate scenario reported by our readers above played out time and time again. Methotrexate (MTX) is an analog of folic acid. It binds tightly to an enzyme called dihydrofolate reductase and when it does so, interferes with the production of tetrahydrofolates. In the end, this interferes with the normal production and repair of DNA by limiting the production of a key nucleotide, thymidine. Other metabolic effects are also known, but the take home message is that MTX can result in lethal damage to cells that are replicating, particularly those that are replicating rapidly, like certain cancer cells.
Because of its documented efficacy in the treatment of malignant trophoblastic cells (choriocarcinoma), MTX has been employed in recent years as an alternative to surgical therapy in selected cases of ectopic pregnancy (Lipscomb, et al. NEJM 2000;343:1325-29). Ectopic pregnancies, by definition, implant ‘outside the uterus’ with more than 95% occurring in the fallopian tubes and about 2.5% in the cornua of the uterus (where the fallopian tubes enter the uterus). For that reason, they are frequently referred to as ‘tubal pregnancies,’ although they can also occur in the cervix, ovary and intraabdominally. The fallopian tubes cannot restrict the growth of invasive placental tissues, as can the endometrium, and they certainly cannot accommodate a growing embryo beyond a certain point before they rupture and hemorrhage. Indeed, ectopic pregnancies can be quite deadly if not treated appropriately. They are still a major cause of maternal mortality, accounting for 10-15% of all maternal deaths, and they are the leading cause of death in pregnant women in the first trimester. A ruptured ectopic pregnancy is a true medical emergency.
Because of the rising incidence of ectopic pregnancy, the risk (maternal and medical-legal) of not identifying and treating an ectopic pregnancy in a timely fashion, and the widespread acceptance and success of MTX therapy as an alternative to surgical management of an ectopic pregnancy if caught early enough, there has been a coincident increase in the inadvertent use of MTX in unrecognized early intrauterine pregnancies. The usual scenario is one in which the pregnancy is not quite as far along as anticipated and the patient happens to present with complaints of abdominal pain or some spotting and no clear intrauterine pregnancy is identified by ultrasound. The ‘absence’ of an intrauterine pregnancy can be misdiagnosed because the pregnancy really is too early, but in at least one of the scenarios above was more likely the result of the inexperience of the individual(s) performing the ultrasound study. This situation can be especially confusing if the pregnancy hormone levels (hCG) appear to be low for the expected gestational age based on last menstrual period (as is often seen in women who ovulate later, and hence conceive later, in their cycles) or if a woman has a tender adnexal mass because a hemorrhagic corpus luteum (intraovarian bleeding at the site from which the egg was ‘hatched’) or torsion of an adnexal mass (rare this early in pregnancy) which might be very difficult to differentiate from an ectopic pregnancy.
Since MTX is a category X drug, known to be teratogenic in humans, it is important to ascertain the presence of an ectopic pregnancy rather than simply to use it empirically. Unfortunately, its use in advertently with an intrauterine pregnancy is most likely to occur during the time of neural tube and very early cardiac development, both of which rely on folate-dependent pathways. Various algorithms are in place that employ ultrasound imaging, quantitative hCG levels, and progesterone levels to differentiate abnormal from potentially normal pregnancies and these protocols can be useful in minimizing the chance of the inadvertent use of MTX and also in directing its use when appropriate for the management of an ectopic pregnancy. Perhaps the greatest risk of ectopic pregnancy is not suspecting that one could be present. Patients who are adequately counseled and followed closely are much less likely to end up in emergency situations.
To our readers above, I am SO SORRY for both of you. This is a failing of the medical system and is a growing concern of mine due to the ready accessibility and simplicity of use of methotrexate (and also another drug, misoprostol, that is used in the 'medical evacuation' of the uterus when an inevitable miscarriage is suspected). My feeling is that it should never be used in an asymptomatic or minimally symptomatic patient until either an ectopic pregnancy is seen, no intrauterine pregnancy is documented (by a competent sonographer) at hCG levels where an intrauterine pregnancy should readily be visible, the patient has significant 'risk factors' for an ectopic pregnancy (e.g., previous ectopic, known history of pelvic inflammatory disease or tubal reconstructive surgery) or when there are well-documented abnormalities in the rise of hCG that are highly suggestive of an ectopic pregnancy. My heart goes out to both of you.
Kind regards,
Dr T
Labels: Ectopic pregnancy, folate metabolism, methotrexate therapy
53 Comments:
At Tue Jul 14, 10:19:00 AM 2009,
Martha said…
I encountered the same problem. I had a previous ectopic so the second time I got pregnant they immediately diagnosed me with ectopic and gave me MTX, the problem was that when I finally miscarried the fetus was already forming. I did some research and found that for the timeline it was actually in fact a fetus. I would like to know for future reference the timeline that would be safe to not misdiagnose ectopic but that also wouldn't risk my life if I had one. The hormone count was not exactly doubling but almost did and the first count after the shot still went up and started to drop about two week after the MTX.
At Tue Jul 14, 12:44:00 PM 2009,
Anonymous said…
Hi Im 5 weeks pregnant and the doctor told me that its possible that i may have a eptopic pregnancy because they found a cyst on my right ovary. They also said that the cyst had an echo. I'm confused what that means, I have HPV and have had cervical dysplacia. I had to have surgery in january. It was a laser. My hormone levels are also low. There was alittle bit of a rise on the 7-11-09 i was 81 and on 7-13-09 i was 305 i'm concerned and wanted to know your opinion. i'm not haveing in different pain accept cramps and back aches.. no bleeding just every once in awhile i will have a brownish discharge.. please help sorry about the writin very nervous
At Tue Jul 14, 05:38:00 PM 2009,
Anonymous said…
I have heard that red rasberry leaf tea helps strengthen your uterus which in turn could help prevent miscarriages. Is there any truth to this?
At Thu Jul 16, 06:36:00 AM 2009,
Anonymous said…
Dr. T:
I have a history of repeat miscarriages. I have had three total. Two, then my daughter was born and I just had another one at 10 weeks pg.
I have heard and read that some women carry male babies or female babies. I was wondering if there was any truth to this or if it was just a myth?
Thank you.
At Sun Jul 19, 05:26:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Martha: Evidence of an intrauterine pregnancy can generally be documented by ultrasound by 17-25 days after ovulation (4.5-5.5) weeks gestation. It would be exceedingly unlikely to get into serious trouble from an ectopic pregnancy by that time. Thanks for writing.
Dr T
At Sun Jul 19, 05:30:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 14: Although your hCG levels were low for "5 weeks", they did double normally during the time period you mentioned. It could be that you just ovulated a few days late. The cyst on the right ovary is probably a 'corpus luteum' cyst. This is the site from which the egg came that became this pregnancy and it will help support the pregnancy during most of the first trimester until the placenta takes over that function. If there were some echoes within the cyst, that may just be some bleeding. When this occurs it is called a 'hemorrhagic corpus luteum
. Good luck and I hope things turn out well.
Dr T
At Sun Jul 19, 05:39:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 14: Red raspberry leaves are a good source of vitamins C and E as well as vitamin A and some B complex. It also contains many essential minerals such as phosphorus, potassium, and an easily digestible form of calcium. Personally, I do not know if this helps to "strengthen the uterus" but it should be relatively safe (if not used to excess) in pregnancy.
Dr T
At Sun Jul 19, 05:47:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 16: Unless someone or their partner has a genetic condition or a chromosomal abnormality that precludes the normal developmenet of either a boy or girl, they should have about a 50:50 chance of having either.
Dr T
At Mon Jul 20, 10:39:00 AM 2009,
Anonymous said…
I am sorry, Doctor. I meant to say I have heard that some woman can't carry female or male babies, not "can". I was wondering if there was any truth to that.
At Tue Jul 21, 08:27:00 AM 2009,
Martha said…
Doctor T,
Thank you for writing back and thank you for all the wonderful help that you provide. I guess the next time around I will seek a second third and fourth opinion to be totally sure. What exams do you recommend in order to measure the possibilities of a successful pregnancy? I would like to be as informed as possible before trying again.
Thanks again,
Martha
At Thu Jul 23, 05:00:00 AM 2009,
WorriedMomtoBe said…
Dear Dr. T:
I know you receive alot of postings but I am BEGGING you if possible to PLEASE respond as I need to make a decision by tomorrow on whether or not to undergo an aminocentesis.
I am pregnant with my second child at age 39, and did not have an amnio with my first child who was born 18 months ago and was healthy. My 12 week ultrasound testing showed normal results, but when I went in for my 18 week ultrasound they found a 1 cm choroid plexus cyst - but no other abnormalities were detected. I requested another ultrasound at week 20 which showed the cyst to have disappeared, but from my understanding this does not mean there may still not be a chance of trisomoy or downs. I was told I have a 1 in 3700 risk of trisomy, but an even greater 1 in 470 risk of downs. Now my worry of Downs is keeping me up and night and I am not sleeping, however my fear of a miscarriage from the amnio is just as concerning and that is making me feel even worse. If I lose a healty baby from the amnio I will be devastated, but I am also not sure how I would cope with having a child with Downs. I am leaning towards not having the amnio but I am not sure I am doing the right thing based on a 1 in 470 chance and what results have shown so far. I have to decide by TOMORROW as my amnio would then not happen until week 21 next week, which I am told is even late to have this scheduled. Is there more risk at a later week than earlier? Please help provide some guidance based on my results, age, and your general knowledge of the amnio procedure.
THANK YOU in advance! THIS SITE IS WONDERFUL!
From, Worried Mom to Be
At Mon Aug 03, 12:30:00 PM 2009,
Anonymous said…
I had an incident in January where i had a positive urine pregnancy test and bleeding, but a negative blood pregnancy test. I truly believe i had an ectopic pregnancy but was never given an ultrasound to look inside pelvis. In Feb, when I finally had an ultrasound, it found I had a hydrosalpinx on in my right tube. It took about 2 months for the pain to go away and I believe the hydrosalpinx resolved itself. So in my case, i was not offered an ultrasound, probably because I didn't have health insurance, but really could have used the information that would have come out of one at that time as i was in major pain. Waiting is always a good idea, especially if you do get an ultrasound and nothing is seen in a tube. Unfortunately, doctors today only care about not getting sued so they jump to the quickest and easiest fix to ensure they will not get sued. It sad how women's health and safety are compromised every single day.
At Thu Aug 13, 06:33:00 AM 2009,
Anonymous said…
I was diagnoised with an ectopic pregnancy on 8-3-09. pregnancy was 7weeks 4 days. Hcg level was 16000. I was given a single dose MTX. Day 4 after injection my level was 19,000 on day 7 it was 13,500. My levels are falling but I have no symptoms such as cramping or spotting. When should I expect this to begin to occur?
At Thu Aug 13, 06:07:00 PM 2009,
Catmarg said…
I have had three miscarriages and next week I am going to see an obgyn for the first time to see if she can find out the problem. The good news is that I found out I am pregnant again. I plan to keep my appointment, but a am worried that she won't be able to help because I am pregnant. Can the doctor still help me to investigate the chance of miscarriage? Usually the obgyn won't see me until 11weeks. What kind of tests can be done while I am pregnant? Thanks for your help.
At Tue Aug 18, 03:35:00 PM 2009,
Anonymous said…
I was given one shot of methotrexate on august 7th. I started I think was a period on august 15th. Could I start trying again by the end of this month or should I wait until my next cycle? I am afriad that if I become pregnant to soon my baby would be at risk. What if I became pregnant this soon?
At Fri Aug 21, 08:09:00 AM 2009,
Anonymous said…
Hello Dr T, I am going through a cervical pregnancy. At 11 wks they did an intervention to terminate it in which they applied an injection of methotrexate vaginally under anesthesia. 2 days after there was still cardiac movement so they applied another injection directly into the foetus heart (potassium or calcium cholride something like that)to terminate cardiac movement. A day after the hcg levels had drop some and cardiac movement was terminated. because they do not want to damage any part so that I can become pregnant again (this is my first at 42) and because it is so low, they are afraid of a hemorragie so they are not touching anything else. I will be going for another ultrasound soon and a follow up blood test but they have talked about a second injection of MTX. I would like to avoid it, what are your thoughts? Also, they plan to do a embolisation of the uterine artery to avoid hemorragie if it comes to that. I would like to avoid a hysterectomy the most possible. Anything I should be careful of? By the way,I am in Europe.
Scaredtodeath
At Tue Aug 25, 03:59:00 PM 2009,
Anonymous said…
this question is not related to the current topic, but i am desparately seeking an answer and hope that you or someone can help.
i live in a rural area and there are mainly general practitioners/ family doctors here, with very few specialists. so i am having difficulty getting an answer to a question that is seriously bothering me.
here is my question/concern:
i am rh - and husband is rh +. last pregnancy i had the rhogam shot around 28 weeks PG and after RH+ baby was born. however, during this pregnancy, i tested positive for "anti-M". this is different than "anti-d" which is what rhogam tries to prevent.... and like most of you, i had NEVER heard of anti-m before. best way i can explain it - basically, i am sensitized to the "m" antibody (no one knows how it happened), just as some people become sensitized to the "D" antibody if they don't receive rhogam and are rh -, and give birth to an rh+ baby.
thankfully the type of "anti-m" i have (IGM) does not cross the placenta, so the baby should not be in danger during this pregnancy. but any blood i receive MUST be screened so that it does not have the M antibody in it, or i could run into real problems.
i know that rhogam is derived from blood. if you read the info packet that comes with rhogam it basically says there is a slight possibility you could get blood borne diseases as a result of rhogam. (i don't have the packet in front of me now so can't give exact wording.) BUT if rhogam is derived from blood, how do i know that rhogam itself DOES NOT CONTAIN the "m" antibody. is rhogam screened to make sure the blood that is used in making it does not contain the "m" antibody? i am worried that if rhogam is not screened for anti-m, getting the injection could cause my body to react, which would certainly NOT be a good thing for me or baby.
also, my doctor has said the rhogam is required at 28 - 30 weeks of pregnancy. i am at 26 weeks now. i expressed my concern to him about rhogam possibly not being screened for anti-m, and he assured me that it was. but i do not think he has any real "proof" of this, nor could present me with any "proof" that i require.
so i am begging anyone out there who can help me. HOW can i get my question answered? i have searched online and cannot find the answer. i live in a very rural area, so there are no real "experts" i can call or ask. i feel trapped and very scared for my baby. i don't want the rhogam to hurt either of us.
thank you to anyone who can help.
At Fri Aug 28, 06:59:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Martha July 21: Simply measuring the quantitative hCG levels and serum progesterone levels early in pregnancy can help offer reassurance.
Dr T
At Fri Aug 28, 07:02:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To worried Mom July 23: Sorry I did not catch this until now. At that low risk for Down syndrome (1 in 470) I would not necessarily recommend an amnio because the overwhelming odds are in your favor the baby is chromosomally normal, especially if the only 'soft marker' found was a choroid plexus cyst. If you check back with us let us know how things turned out. Best wishes!
Dr T
At Fri Aug 28, 07:07:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Aug 13: It is good your hCG dropped that dramatically. Often women with ectopics that have levels that high will require two MTX injections or fail MTX therapy. You will probably start having some bleeding within 10-14 days, but not all women will, especially if the tube is blocked from scarring for some reason. Best of luck!
Dr T
At Fri Aug 28, 07:11:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To catmarg aug 13: It really is better to have a workup for recurrent miscarriages while you are NOT pregnanct. Your doctor could still screen you for thyroid disease and certain thrombophilias such as anticardiolipin antibodies, lupus anticoagulant, factor V Leiden, prothrombin mutation and several others. Serum progesterone and hCG levels may help tell you if things appear to be progressing normally even before a baby is seen. If you miscarry this pregnancy, I suggest you ask that some of the tissue be sent for chromosomal analysis and then wait to get pregnant again until you have had a more thorough evaluation. Hope things go well this time!
Dr T
At Fri Aug 28, 07:16:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous August 25: No you have things mixed up. YOU have the M antibody in your blood as the result of being exposed to red blood cells that have the M antigen on their surface (which you must not have). So you don't want to get exposed to red blood cells that carry M antigen. Rhogam does NOT contain any red blood cells so it doesn't matter in your case if there is any M antibody in there! So yes, you SHOULD get the rhogam since it would be much worse to become sensitized (develop antibodies) to the Rh-antigen D.
Dr T
At Wed Sep 09, 03:38:00 PM 2009,
Anonymous said…
Hi- I would appreciate any insight on my recent pregnancy loss. I had a tubal reversal done two years ago with the result being that one tube was shorter that the RE would have preferred but still gave me a 10% chance of success while the other tube was so small that there was nothing to work with and was "unrepairable". I became pregnant and a week ago (at 6 weeks from LMP) I started bleeding. Nothing heavy and no pain but was sent to ER as my risk for ectopic is so high. My pelvic exam looked good and my bloodwork was good. The doctor thought all was fine but wanted to scan to be certain. The doctor had a difficult time finding my uterus as it is apparently not only tilted but hidden behind my bladder. Once he found my uterus he stated it appeared empty. He did note that there was a mass on my left side fallopian tube that was suspicious (there was no heartbeat) and he wanted a radiologist to confirm that it was ectopic. The radiologist was called in to do a scan and the next thing I knew I was being told that the baby was ectopic and I had blood or fluid (they were unsure) in my belly and needed surgery asap. After the surgery I was told that the fetus was on the outside of the "nub" fallopian tube and the other tube looked good. I am thrilled to know I still have one tube but at the time I was so devastated about losing the baby that I did not think to ask how I could have gotten pregnant from a fallopian tube that was not only so small but should still have been cauterized. Could it possibly have been a corpus luteum and not ectopic? Any insight would be greatly appreciated.
Thank you- Audrey
At Sun Sep 20, 11:23:00 PM 2009,
cpsingh said…
Patient is 30year old with no child yet.
Past history of left sided ectopic which ruptured on 07.12.08 & salpingectomy left sided was done
12.06.09 – LMP , regular cycle of 30 days
20.07.09 – beta hcg – 139.70 mU/ml
22.07.09 - beta hcg – 367.80 mU/ml
23.07.09 – inj hcg 5000 iu i/m
27.07.09 – TVS :(by Dr.Vikas Gupta)
· thickened endometrium-16.4mm
· No gestational sac noted in uterus
· No free fluid in cul-de-sac
30.07.09 - inj hcg 5000 iu i/m
10.08.09 – TVS :(by Dr. Archana Kumar)
· single irregular anechoic intra-uterine gestation sac without embryonic
echoes & Y.S.
· G.S. is approx. – 8.3mm , corresponding to 4 week 6 days
· Cardiac activity not visualized
· Decidual reaction is poor
· No free fluid in pouch of Douglas
( I think, it was probably pseudosac which was wrongly interpreted as intra uterine pregnancy by Dr. Archana Kumar)
11.08.09 - beta hcg – 22500 mU/ml
12.08.09 - inj hcg 5000 iu i/m
18.08.09 –TVS :(by Dr. Archana Kumar)
· single well defined complex mass of approx. 30x33mm seen in Rt adnexa.
· Mass is showing moderate vascularity
· No evidence of live embryo or YS seen inside the mass
· U/S findings are more in favour of Right adnexal ? Ectopic pregnancy
18.08.09 – TVS (by Dr.Vikas Gupta)
· there is evidence of 36.5x25.2mm sized centrally anechoic peripheral echogenic focal lesion noted at proximal most part of right fallopian tube abutting right side of uterus with increase vascularity on Doppler -? Right sided early ectopic pregnancy ?? nature.
· Endometrium thickening – 16.5mm
· Minimal free fluid in cul-de-sac.
21.08.09 - beta hcg – 12060 mU/ml
21.08.09 –TVS (by Dr. Monika Saxena)
· evidence of thick walled ~30x29mm sized echogenic lesion with central gestational sac & fetal pole inside of CRL measuring~7.0mm is noted at right adnexa just at cornuotubal end of uterus with increase peripheral vascularity.
· No cardiac activity in fetal pole suggesting Ectopic pregnancy at right fallopian tube just at its origin from uterus
· Endometrium thickening – 22.0mm
· Mild free fluid in cul-de-sac
27.08.09 –TVS (by Dr. Monika Saxena)
· evidence of thick walled ~30x30mm sized echogenic lesion with central gestational sac & fetal pole inside of CRL measuring~7.0mm is noted at right adnexa just at cornuotubal end of uterus with increase peripheral vascularity.
· No cardiac activity in fetal pole suggesting Ectopic pregnancy at right fallopian tube just at its origin from uterus
· Mild free fluid in cul-de-sac
27.08.09 - beta hcg – 7660 mU/ml
28.08.09 – First shot of inj methotrexate 50mg i/m
30.08.09 – Second shot of inj methotrexate 50mg i/m
08.09.09 – TVS(by Dr. Monika Saxena)
· evidence of thick walled ~33x42mm sized echogenic lesion with central gestational sac & fetal pole inside of CRL measuring~7.0mm is noted at right adnexa just at cornuotubal end of uterus with increase peripheral vascularity.
· No cardiac activity in fetal pole suggesting Ectopic pregnancy at right fallopian tube just at its origin from uterus
· No free fluid in cul-de-sac
· Endometrium – 7.0mm
08.09.09 - beta hcg – 545 mU/ml
11.09.09 –Repeat shot of inj methotrexate 75mg i/m
13.09.09 – inj methotrexate 75mg i/m
methotrexate in ectopic pregnancy is said to be responding well if beta hcg level is falling down (more than 15%) but what happens to gestational mass?
Ø In how much time it (gestation mass) is resolved/aborted?
Ø Up to what time we should wait for ectopic to be resolved/aborted from tube(when beta hcg is declining)
Ø With declining beta hcg , whether its(gestation mass) size reduces gradually or not
Ø How can we know the response of methotrexate in respect to gestation mass
In this above particular case , kindly comment on the course & fate of gestation mass on treatment with methotrexate and how to measure response of methotrexate in respect to gestation mass.
Kindly give your valuable advice on further course of treatment & line of management in this above mentioned particular case.
At Fri Sep 25, 12:23:00 PM 2009,
Anonymous said…
I am interested in your thoughts on my situation. I’m 37 with no children and currently very early in what could be my 5th pregnancy (none of the previous lasted past 6 weeks). I have low and slow-rising HCG levels. First HCG at 14 days past ovulations was 46, second 102, third 125 and fourth 200. All were 48 hours apart. They are now thinking it may be ectopic and I have a scheduled ultrasound on Tuesday. I had an assumed ectopic in July 2008 – HCG was 1600 and not doubling, they didn’t see anything in the uterine cavity or tubes and I was treated with Methotrexate. Following that, I had an HSG done and the tubes were open and everything looked normal. Is there any chance the current pregnancy is viable? Are there risks in taking Methorexate again?
At Tue Sep 29, 02:45:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To cpsingh sep 20: It sounds like this is a cornual ectopic pregnancy, perhaps in the wall of the uterus itself where the tube enters the uterus. These are especially dangerous becuase of their risks for rupture and hemorrhage, even as they are resolving. The effectiveness of the methotrexate will be measured by the fall in hCG. After a week or so, it should steadily decline. It might take awhile for the mass to resolve - weeks or even months as the body absorbs the pregnancy tissues. Following this, if pregnancy is desired, I recommend consultation with a specialist in reproductive endocrinology and infertility - first to evaluate the uterus and then to assist with another pregnancy. IVF may be warranted or necessary under these circumstances. Kind regards,
Dr T
At Tue Sep 29, 02:49:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous sep 25: That is not a normal increase in hCG and it could indicate another ectopic or simply a nonviable intrauterine pregnancy. At the current hCG levels it will be very difficult to establish the location of the pregnancy by ultrasound alone so I would be cautious about taking MTX until that has been done with a relative degree of certainty. At the dosage regimens we use for ectopic pregnancies, it should be relatively safe to receive repeated courses of MTX if this is another ectopic. I am sorry for the problems you have had and wish you the best.
Dr T
At Mon Oct 05, 05:38:00 PM 2009,
Nazneen said…
Hello Doctor,
I just got to know of this site and I feel I am at the right place. I am 34 years old and 23 weeks pregnant. I had all my prenatal screening test which came back negative for downs/trisomy/spina bifida. I had my 18 weeks fetal anatomy and as per my doctor the results said they suspected an abnormality in the heart, but nothing was detected. I am really worried on hearing this as now I really wonder if everything is fine with my baby.
Should I request my doctor for another u/s or test. Please respond soon so I can put my mind to use and take the next correct step as per your advise.
Thanks
At Thu Oct 08, 04:11:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Nazneen: I am not sure I understand. Did your doctor suspect a heart abnormality and then send you to a specialist who did not find one? What was the abnormality your doctor found? You probably do not have anything to worry about. It is very unlikely the baby has any kind of significant problem! Best wishes.
Dr T
At Wed Oct 14, 11:00:00 AM 2009,
Anonymous said…
Hi Dr. T.
In response to your ques to my blog on Oct 5th. I went for my 18 week fetal anatomy and the tech did entire ultrasound except for the heart as she told me the baby was lying on his stomach and she could not get a proper view.
So I re scheduled and had to go for another u/s a few days later.
When I went to the my OB he said that the tech had suspected some abnormality in the baby but nothing could be detected. That was it, I was never referred to any other specialist.
So I am wondering if everything is fine or should I request another u/s. Please advise.
At Thu Oct 15, 06:02:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 14: I suggest another ultrasound with a specialist in maternal-fetal medicine. Best wishes.
Dr T
At Sat Oct 17, 03:32:00 PM 2009,
Nazneen said…
I went for an ultrasound at 24 weeks and they found an echogenic intracardiac focus of 2.2 cm. Other integragted prenatels tests showed negative for downs.triosnmy/spina bifida. My OB says everything is fine but i read that EIF is a softmarker for downs.Please advise
Do you think I should ask him to refer me to a specialist. Please advise. Thanks
At Mon Oct 19, 10:24:00 AM 2009,
Nazneen said…
Hello Dr.
Sorry for writing another blog as I really want to make sure I am explaining myself as I am so worried.
I am 34 years old I had my u/s at 25 weeks 1 days and below are the details as worded in my u/s report.
BPD 6.27 cm
Head circum 23.02cm
abdominal circum 19.70 cm
femur length 4.79 cm
Fetal weight 770 gms which lies between 35 to 40 percentile abd is within 2 standard deviations.
A 4 chamber heart was seen and contains a 2.2 cm intracardiac focus. A 3 vessel umblical cord is noted.
Dr what i am worried about is the Echogenic intracardiac Focus as I heard this is a soft marker for downs also I do not understand medical terms and am very confused with the fetal wt. which says 35 to 40 percentile.
I am really worried and appreciate any advise you give me at this time. Whether I should ask my OB for an amnio or further u/s.
Thanks
Nazneen
At Mon Oct 19, 02:57:00 PM 2009,
Anonymous said…
hi im 25 wks pregnant now..and my baby has a cystic hygroma and hydrops in her belly...the doc's are very vague with us and really explain much to us or let us know any kind of updates? if you can help with anything or give us any more information (any information) that would be great!!
At Tue Oct 20, 07:55:00 AM 2009,
Kayondo said…
Dear Dr,
I had a miscarriage last year at 11 wks which was followed by a chemical. I was then put on progesterone and carried a pregnancy to full term but the baby had dilated cardiomyopathy and hence ended into a stillbirth.
I conceived four months later and have gone on to have four consective chemical pregnancies. Tests like brucella, toxo, coombs, thyroid hormones hv all been ok. Tissue from the 1st miscarriage was tested and showed endometrial glands showing arias stella reaction. cyto and syncytiocytotrophoblasts. Is there any chance of me having a normal baby? And is it possible that the progesterone supplements could have caused the heart defect?
Carol
At Tue Oct 20, 05:38:00 PM 2009,
Amber said…
Hi Dr. T
I am 32 years old and was diagnosed with a partial molar pregnancy on 9/16/08; since then I have had two miscarriages one on 2/13/09 and the other on 8/17/09. I saw two different drs at the same office for treatment of the miscarriages. The first dr told me that the miscarriage was normal and with no signs of molar tissue and I could wait two months to try and conceive again. The second dr told me that he thought my miscarriages had something to do with the molar becuase of the irregular pathology reports. I got copies of both reports they appear similar:
Results of first miscarriage stated:
"Products of conception showing endometrium in secretory phase with arias stella reaction, scanty fragments of chorionic villi and syncytial trophoblastic proliferation"
Results of 2nd miscarriage
"Products of conception showing endometrium in secretory phase with arias-stella reaction and rare chorionic villi"
ARE THESE RESULTS THE SAME?? I am confused because I got two different answers from two different drs. Also the first m/c was not tested for chromosomal errors but the 2nd m/c was missing the 21 chromosome. Can you provide any insight as to the patholgy reports and if there is something else I should be looking for? I am going in for testing to see if there are any other causes for my miscarriages. I really appreciate your assistance.
Thank you
At Tue Oct 20, 05:41:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Nazneen: The results mean you have an average-sized baby with an echogenic cardiac focus ( a VERY 'soft' and unreliable marker for Down syndrome). Because of your concerns, I would suggest a good ultrasound with a specialist in Maternal-Fetal Medicine and reserve making any decisions regarding an amniocentesis pending that evaluation. Best wishes!
Dr T
At Tue Oct 20, 05:45:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 19: There are many, many causes for fetal hydrops and cystic hygromas. This late in pregnancy, neither finding bodes well unless a cause can be determined and corrective measures taken if possible. Fetal anemia is certainly a 'correctible' cause of hydrops by intrauterine transfusion, but a chromosomal abnormality, major cardiac defect, congenital infection, or inborn error of metabolism may not be. Best wishes and please let us know what you find out.
Dr T
At Tue Oct 20, 05:49:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Carol: Do they have any reason at all for why your baby had a dilated cardiomyopathy. Were you on ANY medications, taking any 'herbal remedies, have a thyroid problem or diabetes? Did the baby have pulmonary hypertension? Have you ever been screened for an autoimmune condition or tested for anti-Ro (SS-A) or anti-La (SS-B) antibodies?
Dr T
At Wed Oct 21, 05:08:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amber Oct 20: The results are the same - you simply had two early miscarriages. There is nothing 'atypical' about those pathology reports. Best of luck next time!
Dr T
At Wed Oct 21, 07:09:00 PM 2009,
Amber said…
Dr T.
Thank you for your response regarding my pathology reports. I saw my primary dr today(who is a midwife)for a work up to see if there is anything causing the miscarriages. I told her that I was thinking about switching drs becuase of the different responses I got. The 2nd dr said I should wait 6 months to try to conceive again; so my body can fully recover. They said if I wait 6 months I will have a better chance at a healthy pregnancy. My questions is this: Is there really a physical difference if I wait 2-3 months compared to 6th months before I try again? I'm sure you are asked this question a lot and I would appreciate your opinion. I'm not sure how much I agree woth there reasoning becuase I waited 4 months after the first miscarriage and had another one. Again I appreciate your advice and am happy that I have found your forum as reading the various posts has given me a lot of insight.
At Fri Oct 23, 04:17:00 PM 2009,
Anonymous said…
Dr T,
I am so happy to have found this website. I am quite a worrier and I am trying my best to be strong throughout this ordeal. I received a shot of MTX yesterday. I had IVF where 2 blast transfers were implanted. It came back positive, but here were my numbers that lead to a suspected ectopic or unhealthy uterine pregnancy.
10dpt-(beta)25
12dpt-33
14dpt-68
17dpt-171
19dpt-231 u/s (nothing seen) sugeested MTX shot
21dpt-215 i still wanted to wait
23dpt-185 started to come down
25dpt-232 Suggested shot again
26dpt-274 Agreed to shot
My doctor does believe it is an unhealthy uterine pregnancy and said MTX is the safest route for me right now, to avoid a possible suregery. I am still a nervous wreck, even to have this scary medicine in me. I am also afraid of an ectopic still happening. My levels aren't out of control, but I have read horror stories. I hate living in this fear. i hope and pray I made the right decision in getting it, and I am anxious to have it out of my system. I go back on friday for another Beta. Thanks for your opinion!
At Tue Nov 03, 07:24:00 AM 2009,
eve said…
please help
I am 27 years old
NT-1,6
HCG-0.659 MOM
PAPP-a-2.293 MOM
they say to go to amino.
I would just like to know what does is means when Papp-a is to high.
At Tue Nov 03, 06:32:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amber Oct 21: I usually recommend waiting 2-3 months myself. This gives the lining of the uterus a chance to recover from any residual inflammatory reactions from remaining products of conception. But I also know many women who have conceived during the first or second cycle following a miscarriage and have done just fine. You try again when YOU are ready! There is no right answer to this question.
Dr T
At Tue Nov 03, 06:37:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 23: Based on the hCG levels, this was not a good pregnancy, regardless of location. You should be fine with the MTX. Best wishes and I am so sorry.
Dr T
At Tue Nov 03, 06:41:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Eve Nov 3: High PAPP-A is a challenge. You either have a placenta that is making increased levels or you are not clearing the PAPP-A your placenta is making. I am not aware of a good correlation between elevated PAPP-A and chromosomal abnormalities. It can be seen in women who have chronic kidney disease who do not get rid of the PAPP-A efficiently. So, at this point, the pregnancy implications for the elevation depend on the REASON for the elevation. If you just have a big healthy placenta, that may be good. If you have underlying kidney disease of which you are unaware, that may not be so good! Best wishes and please let us know how things turn out.
Dr T
At Wed Nov 11, 08:59:00 AM 2009,
Nazneen said…
Hi Dr.
On finding EIF in my 18 weeks u/s which is the only marker, my dr did not seem too concerned. However I asked him to send me for an echo cardiogram, in my 25th week. The result of the echo as per my dr said that there is nothing to worry about. Does that lower my risk for a baby with DS or I just have to stress and wait for the baby to be born to make sure he is healthy. My integrated prenatal screening in 12th and 16th week came back 1:20000 for downs and 1:8000 for NTD and I am 34 years of age. Please advise should I go for any other testing, kindly advise. Thanks Najji
At Thu Nov 12, 05:56:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Najii Nov 11: Tell you what. If your baby has Down syndrome, based on what you have told me, I will stop answering questions on this blog!!!! Let us know when your NORMAL baby is born.
Dr T
At Fri Nov 13, 10:42:00 AM 2009,
Najji said…
Hi Dr.
Thank you so much for answering my question so positively and confidently. I really wish my OBY was half as positive or confident as you, then we pregnant ladies would not have to stress ourselves. YOU ARE INDEED A BLESSING to us and I will surely let you know once my baby is born.
Thanks Najji
At Sat Nov 14, 08:37:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Najji: Thank you for the kind comments. Take care.
Dr T
At Tue Nov 17, 07:06:00 PM 2009,
Anonymous said…
hello Dr T
i have a question. i have been diagnosed for a possible/suspected ectopic on 11/10. the US, TVS did not reveal a viable pregnancy.
Had a MTX shot on 11/10 and on 11/9 my HCG was 4513. went for a bloodwork on 11/14 and 11/17. my OB/Gyn called me today and he said the following results
11/14 - 6697, 11/17 - 5405. he told me that he is seeing the levels to drop down.
thanks for all your blogs which helped me what to expect. One thing which is not clear to me is that
1. i dont have any symptoms of bleeding yet. had very minor cramps. - when should i really expect to bleed? For some reasons i am thinking if i start to bleed (normally) somehow my pregnancy is coming to an end. is it safe to assume like this?
2. my doctor tells me that i could still rupture. what hcg levels are considered safe for not ending up with a tubal rupture?
3. third is the folic acid - every product cultivated in this world has folates/folic acid. i think it depends on what level of folates these food contain. now my question is how much folates content is still safe to consume while going thru the MTX treatment? is there anyway to destroy the folic acid while cooking? for the long story to cut short, how does one survive without eating any staple meal?
please help!! it would only help me better.
At Fri Nov 27, 02:08:00 AM 2009,
eve said…
Dr.T
I wrote to you a month ago about high PAPP-a(NT-1,6/HCG-0,659MOM/PAPP-a-2,293MOM).
Today I was at the Doctors,and she said that this is a sign of some genetics problem and said to go to amnio(I refused), and than she said if anything thurns up on the next expert ultrasound, than to come again.What do you think?
At Sat Nov 28, 01:50:00 PM 2009,
Anonymous said…
hello Dr T
follow up to my post on Nov 17th 2009.
my blood levels did not drop down during the 2nd week. i'd light headedness and feeling faint...
the doctor did the transvaginal US again and he saw the gestational sac!! he still wasnt sure whether it was viable pregnancy. he recommended to do a D&C and i did it.
the pathology results confirmed that it was having pregnancy tissues after the D&C. My doctor called me that at this point of time, he considers that myself having ectopic pregnancy is low.
please advise if D&C was ever done to confirm the intra-uterine pregnancy vs ectopic!! not because i dont trust my doctor but it would be of great help to reassure this.
dealing with the emotions is so hard right now for me!
please help.
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